ASD Treatment - 10.10 Mc Dougle 2010

8/2/2019 ASD Treatment - 10.10 Mc Dougle 2010

1/8

1

1

Christopher J. McDougle, MDChristopher J. McDougle, MDAlbert E. Sterne Professor andAlbert E. Sterne Professor and

ChairmanChairmanDepartment of PsychiatryDepartment of Psychiatry

Indiana University School of MedicineIndiana University School of Medicine

Psychopharmacology of AutismPsychopharmacology of Autism

2

3

Potential Targets ofPotential Targets ofPharmacotherapyPharmacotherapy

1.1. Motor hyperactivity, inattentionMotor hyperactivity, inattention

2.2. Repetitive behaviorRepetitive behavior

3.3. Aggression, selfAggression, self--injury, propertyinjury, propertydestructiondestruction

4.4. Impaired social relatednessImpaired social relatedness

4






5

Stimulants in AutismStimulants in Autism Historical data and beliefs negativeHistorical data and beliefs negative

Small studies support use of MPH inSmall studies support use of MPH inautismautism1,21,2

Anecdotal reports of a high frequency ofAnecdotal reports of a high frequency ofadverse drug effects includingadverse drug effects includingstereotypies and social withdrawalstereotypies and social withdrawal

MPH = methylphenidate.MPH = methylphenidate.11Quintana H et al.Quintana H et al. J Autism Dev DisordJ Autism Dev Disord. 1995;25:283. 1995;25:283--294.294.22Handen BL et al.Handen BL et al. J Autism Dev DisordJ Autism Dev Disord. 2000;30:245. 2000;30:245--255.255. 6

RUPP Autism Network Study of MPH inRUPP Autism Network Study of MPH in

Children With PDD + HyperactivityChildren With PDD + Hyperactivity

72 Children (age, 572 Children (age, 514 y) with autism,14 y) with autism,Aspergers Disorder, or PDD NOS andAspergers Disorder, or PDD NOS andsignificant ADHD symptomssignificant ADHD symptoms

Study designStudy design

77--day testday test--dose perioddose period

44--week doubleweek double--blind trial of 3 dose levelsblind trial of 3 dose levels(0.125, 0.25, 0.50 mg/kg/dose) of MPH TID(0.125, 0.25, 0.50 mg/kg/dose) of MPH TIDand placebo in random orderand placebo in random order

PDDNOS = pervasive developmental disorder not otherwise specified.PDDNOS = pervasive developmental disorder not otherwise specified.

ADHD = attention deficit/hyperactivity disorder.ADHD = attention deficit/hyperactivity disorder.

RUPP Autism Network.RUPP Autism Network. Arch Gen PsychiatryArch Gen Psychiatry2005; 62:12662005; 62:1266--12741274..


2/8

2

7

TestTest--Dose PhaseDose Phase 6 out of 72 subjects were unable to6 out of 72 subjects were unable to

toleratetolerate2 dose levels of MPH and were dropped2 dose levels of MPH and were droppedfrom the studyfrom the study

16 out of the remaining 66 subjects had16 out of the remaining 66 subjects hadintolerable adverse effects at the highestintolerable adverse effects at the highestdose of MPH; entered modified crossoverdose of MPH; entered modified crossoverphasephase

Irritability was the most common reasonIrritability was the most common reasonfor intolerabilityfor intolerability

RUPP Autism Network.RUPP Autism Network. Arch Gen PsychiatryArch Gen Psychiatry2005; 62:12662005; 62:1266--1274.1274. 8

Crossover PhaseCrossover Phase

58/66 subjects completed the crossover58/66 subjects completed the crossoverphasephase

7 subjects dropped out due to intolerable7 subjects dropped out due to intolerableadverse effectsadverse effects

There was a statistically significant mainThere was a statistically significant maineffect of dose of MPH on the ABCeffect of dose of MPH on the ABCHyperactivity subscale score as rated byHyperactivity subscale score as rated byboth teacher (Primary Outcome Measure; Pboth teacher (Primary Outcome Measure; P=.009) and parent (P


3/8

3

13

Treating Hyperactivity:Treating Hyperactivity:Other MedicationsOther Medications

Clonidine efficacious in 2 small placeboClonidine efficacious in 2 small placebo--controlled trialscontrolled trials1,21,2

OpenOpen--label guanfacine in RUPP MPHlabel guanfacine in RUPP MPHnonresponders is positive, suggesting thatnonresponders is positive, suggesting thatguanfacine may be an alternativeguanfacine may be an alternative33

1Jaselskis CA et al. J Clin Psychopharmacol. 1992;12:322-327.2Fankhauser MP et al. J Clin Psychiatry. 1992;53:77-82.3Scahill L et al. J Child Adolesc Psychopharmacol. 2006;16(5):589-598.

14

Atomoxetine inAtomoxetine inHigherHigher--Functioning PDDFunctioning PDD

Prospective openProspective open--label study in 16 druglabel study in 16 drug--free children (age, 6free children (age, 614 y) with PDDs14 y) with PDDsand nonverbal IQ of 70and nonverbal IQ of 70

Significant ADHD symptomsSignificant ADHD symptoms

Atomoxetine dosing: 0.5 mg/kg/d x 1 wk,Atomoxetine dosing: 0.5 mg/kg/d x 1 wk,then 0.8 mg/kg/d x 1 wk, then 1.2then 0.8 mg/kg/d x 1 wk, then 1.2mg/kg/d. Dose increased to 1.4 mg/kg/dmg/kg/d. Dose increased to 1.4 mg/kg/dat Week 4 for nonrespondersat Week 4 for nonresponders

Mean dose: 1.2Mean dose: 1.2 0.3 mg/kg/d0.3 mg/kg/dPosey DJ et al. J Child Adolesc Psychopharmacol, 2006; 16(5):5992006; 16(5):599--610610.

15

Atomoxetine in PDD WithAtomoxetine in PDD WithADHD SymptomsADHD Symptoms

12/16 (75%)12/16 (75%) muchmuchoror very much improvedvery much improvedon the CGI scaleon the CGI scale

2/16 (13%)2/16 (13%) much worsemuch worsedue to irritabilitydue to irritability

ConclusionsConclusions

Encouraging resultsEncouraging results

Possible alternative to stimulants andPossible alternative to stimulants and22--adrenergic agonistsadrenergic agonists

PlaceboPlacebo--controlled studies neededcontrolled studies needed

CGI = Clinical Global Impressions.

Posey DJ et al. J Child Adolesc Psychopharmacol, 2006; 16(5):5992006; 16(5):599--610610. 16

17

Potential Targets ofPotential Targets of

PharmacotherapyPharmacotherapy





18

Serotonin ReuptakeSerotonin Reuptake

Inhibitors (SRIs)Inhibitors (SRIs)

Rationale for studying SRIs in autismRationale for studying SRIs in autism

Similarities to obsessiveSimilarities to obsessive--compulsive disordercompulsive disorder

Serotonin abnormalities in autismSerotonin abnormalities in autism


4/8

4

19

SRIs in AutismSRIs in Autism Clomipramine better than placebo andClomipramine better than placebo and

desipramine in children and young adultsdesipramine in children and young adultswith autismwith autism11

Fluvoxamine better than placebo inFluvoxamine better than placebo inADULTSADULTSwith autismwith autism22

Fluvoxamine no better than placebo andFluvoxamine no better than placebo andpoorly tolerated inpoorly tolerated in CHILDRENCHILDREN with PDDswith PDDs33

Fluoxetine better than placebo and welltolerated in children with PDDs4

1Gordon CT et al.Arch Gen Psychiatry. 1993;50:441-447.2McDougle CJ et al.Arch Gen Psychiatry. 1996;53:1001-1008.3McDougle CJ. Unpublished data.4Hollander E et al. Neuropsychopharmacology. 2005; 30:582-589. 20

Citalopram in PDDsCitalopram in PDDs

149 children (9.4149 children (9.4 3.1 years) with PDDs and significant3.1 years) with PDDs and significant

repetitive behaviorrepetitive behavior 1212--week, doubleweek, double--blind, placeboblind, placebo--controlled, parallel groupscontrolled, parallel groups

designdesign

Citalopram started at 2.5 mg/day; max dose = 20 mg/day;Citalopram started at 2.5 mg/day; max dose = 20 mg/day;(mean dose = 16.5(mean dose = 16.5 6.5 mg/day)6.5 mg/day)

No drugNo drug--placebo difference in response on CGIplacebo difference in response on CGI--I or in scoreI or in scorereduction on CYreduction on CY--BOCSBOCS--PDDPDD

Significantly more adverse events with citalopram thanSignificantly more adverse events with citalopram thanplacebo: increased energy level, impulsiveness, decreasedplacebo: increased energy level, impulsiveness, decreasedconcentration, hyperactivity, stereotypy, diarrhea, insomnia,concentration, hyperactivity, stereotypy, diarrhea, insomnia,and dry skin or pruritusand dry skin or pruritus

King BH et al. Arch Gen Psychiatry. 2009; 66(6):583-590.

21 22






23

Typical AntipsychoticsTypical Antipsychotics

Several RCTs of haloperidol associatedSeveral RCTs of haloperidol associatedwith improvement in a variety ofwith improvement in a variety ofsymptoms including aggression andsymptoms including aggression andirritabilityirritability

Adverse effects: dystonia, dyskinesiasAdverse effects: dystonia, dyskinesias

RCT = randomized clinical trial.

Anderson LT et al.Am J Psychiatry. 1984;141:1195-1202.

Campbell M et al. J Am Acad Child Adolesc Psychiatry. 1997;36:835-843.24

Atypical AntipsychoticsAtypical Antipsychotics Serotonin antagonism in addition to dopamineSerotonin antagonism in addition to dopamine

antagonismantagonism

Lower risk of dyskinesiasLower risk of dyskinesias

Individual drugs includeIndividual drugs include

ClozapineClozapine

RisperidoneRisperidone

OlanzapineOlanzapine

QuetiapineQuetiapine

ZiprasidoneZiprasidone

AripiprazoleAripiprazole

PaliperidonePaliperidone


5/8

5

25

ClozapineClozapine

Case reports onlyCase reports only

Can lower the seizure thresholdCan lower the seizure threshold

Risk of agranulocytosisRisk of agranulocytosis

Frequent blood draws necessaryFrequent blood draws necessary

26

Risperidone in Children WithRisperidone in Children WithAutism and Serious BehavioralAutism and Serious Behavioral

ProblemsProblemsRUPP Autism NetworkRUPP Autism Network

Indiana University (Christopher J. McDougle, MD)Indiana University (Christopher J. McDougle, MD)

KennedyKennedy--Kreiger, Johns Hopkins (Elaine Tierney, MD)Kreiger, Johns Hopkins (Elaine Tierney, MD)

Ohio State University (Michael G. Aman, PhD; L. EugeneOhio State University (Michael G. Aman, PhD; L. EugeneArnold, MD)Arnold, MD)

Yale Child Study Center (Larry Scahill, MSN, PhD)Yale Child Study Center (Larry Scahill, MSN, PhD)

UCLA (James T. McCracken, MD)UCLA (James T. McCracken, MD)

NIMH (Benedetto Vitiello, MD)NIMH (Benedetto Vitiello, MD)

27

Acute Risperidone Trial: RUPPAcute Risperidone Trial: RUPPin Children and Adolescentsin Children and Adolescents

101 subjects (82 boys, 19 girls)101 subjects (82 boys, 19 girls)

Diagnosis: autistic disorderDiagnosis: autistic disorder

Significant irritability (ABC IrritabilitySignificant irritability (ABC Irritability 18)18)

8 weeks, double8 weeks, double--blind, placeboblind, placebo--controlled,controlled,

parallel groupsparallel groups Mean age = 8.8Mean age = 8.8 2.7 y; range = 52.7 y; range = 517 y17 y

Risperidone 1.8 mg/d; range = 0.5Risperidone 1.8 mg/d; range = 0.53.5 mg/d3.5 mg/d

RUPP Autism Network. N Engl J Med. 2002;347:314-321. 28

Acute Risperidone Trial: RUPPAcute Risperidone Trial: RUPP

12%

69%

0

20

40

60

80

100

Risperidone Placebo

Percent

Responding

Response criteria: 25% improvement in the ABC-I score, and arating of much improved or very much improved on the CGI-I

(34/49)(34/49)

(6/52)(6/52)

PP< 0.001< 0.001

ABC-I = Aberrant Behavior ChecklistIrritability.

CGI-I = Clinical Global ImpressionsImprovement.

RUPP Autism Network. N Engl J Med. 2002;347:314-321.

29

Acute Risperidone Trial: RUPPAcute Risperidone Trial: RUPPAdverse effectsAdverse effects

Mean increase in weightMean increase in weight

Risperidone, 2.7Risperidone, 2.7 2.9 kg2.9 kg

Placebo, 0.8Placebo, 0.8 2.2 kg;2.2 kg; PP< 0.001< 0.001

Increased appetite, fatigue, drowsiness,Increased appetite, fatigue, drowsiness,dizziness, and drooling were more commondizziness, and drooling were more commonin the risperidone group; allin the risperidone group; all PP< 0.05< 0.05

AIMS and SimpsonAIMS and Simpson--Angus: no EPSAngus: no EPS

AIMS = Abnormal Involuntary Movement Scale.

EPS = extrapyramidal symptoms.

RUPP Autism Network. N Engl J Med. 2002;347:314-321.30

Baseline and EndpointBaseline and Endpoint

ABC Scores by GroupABC Scores by GroupRisperidoneRisperidone PlaceboPlacebo

ABCABC BaselineBaseline EndpointEndpoint BaselineBaseline EndpointEndpoint

IrritabilityIrritabilityPP< 0.001< 0.001

26.2 (7.9)26.2 (7.9) 11.3 (7.4)11.3 (7.4) 25.5 (6.6)25.5 (6.6) 21.9 (9.5)21.9 (9.5)

SocialSocialWithdrawalWithdrawalPP= 0.03/NS= 0.03/NS

16.4 (8.2)16.4 (8.2) 8.9 (6.4)8.9 (6.4) 16.1 (8.7)16.1 (8.7) 12.0 (8.3)12.0 (8.3)

StereotypyStereotypyPP< 0.001< 0.001

10.6 (4.9)10.6 (4.9) 5.8 (4.6)5.8 (4.6) 9.0 (4.4)9.0 (4.4) 7.3 (4.8)7.3 (4.8)

HyperactivityHyperactivityPP< 0.001< 0.001

31.8 (9.6)31.8 (9.6) 17.0 (9.7)17.0 (9.7) 32.3 (8.5)32.3 (8.5) 27.6 (10.6)27.6 (10.6)

InappropriateInappropriateSpeechSpeech

PP= 0.03/NS= 0.03/NS

4.8 (4.1)4.8 (4.1) 3.0 (3.1)3.0 (3.1) 6.5 (3.6)6.5 (3.6) 5.9 (3.8)5.9 (3.8)

RUPP Autism Network. N Engl J Med. 2002;347:314-321.


6/8

6

31

RUPP RisperidoneRUPP Risperidone Parent Management TrainingParent Management Training

TrialTrial 124 children (4 to 13 years) with PDDs and124 children (4 to 13 years) with PDDs and

significant irritabilitysignificant irritability

2424--week, threeweek, three--site, randomized, parallelsite, randomized, parallelgroups trialgroups trial

Children randomized 3:2 to COMB (n=75) orChildren randomized 3:2 to COMB (n=75) orMED (n=49)MED (n=49)

Parents in COMB received a mean of 10.9Parents in COMB received a mean of 10.9PMT sessionsPMT sessions

RUPP Autism Network. J Am Acad Child Adolesc Psychiatry. 2009;48(2):1143-1154.

32

RUPP RisperidoneRUPP Risperidone Parent Management TrainingParent Management Training

TrialTrial

Primary Outcome Measure (Home SituationsPrimary Outcome Measure (Home SituationsQuestionnaire [HSQ]); COMB > MED (P=.006)Questionnaire [HSQ]); COMB > MED (P=.006)

COMB > MED on ABC Irritability (P=.01),COMB > MED on ABC Irritability (P=.01),Stereotypic Behavior (P=.04), andStereotypic Behavior (P=.04), andHyperactivity/Noncompliance (P=.04)Hyperactivity/Noncompliance (P=.04)

Final Risperidone dose for MED (2.26 mg/day) vs.Final Risperidone dose for MED (2.26 mg/day) vs.COMB (1.98 mg/day) (P=.04)COMB (1.98 mg/day) (P=.04)

ABC = Aberrant Behavior Checklist.

RUPP Autism Network. J Am Acad Child Adolesc Psychiatry. 2009;48(2):1143-1154.

33 34

Olanzapine vs. HaloperidolOlanzapine vs. Haloperidol

12 children with autism (7.812 children with autism (7.8 2.1 y)2.1 y)

66--week openweek open--label, parallel groupslabel, parallel groups

Olanzapine 7.9Olanzapine 7.9 2.5 mg/d2.5 mg/d

Haloperidol 1.4Haloperidol 1.4 0.7 mg/d0.7 mg/d

Response: Olanzapine 5/6 Haloperidol 3/6Response: Olanzapine 5/6 Haloperidol 3/6

Weight Gain:Weight Gain:Olanzapine 9.0Olanzapine 9.0 3.5 lbs; range 5.93.5 lbs; range 5.9 15.8 lbs15.8 lbs

Haloperidol 3.2Haloperidol 3.2 4.9 lbs; range4.9 lbs; range -- 5.55.5 8.8 lbs8.8 lbs

Malone RP et al. J Am Acad Child Adolesc Psychiatry. 2001;40:887-894.

35

OlanzapineOlanzapine DoubleDouble--Blind,Blind,

Placebo Controlled StudyPlacebo Controlled Study 11 children with pervasive developmental11 children with pervasive developmental

disorders (9 y)disorders (9 y)

88--week, doubleweek, double--blind, placeboblind, placebo--controlledcontrolled

Olanzapine 10Olanzapine 10 2.04 mg/d2.04 mg/d

Response: Olanzapine 3/6 Placebo 1/5Response: Olanzapine 3/6 Placebo 1/5

Weight Gain: Olanzapine 7.5Weight Gain: Olanzapine 7.5 4.8 lbs4.8 lbs

Placebo 1.5Placebo 1.5 1.5 lbs1.5 lbs

Hollander E et al. J Child Adolesc Psychopharmacol. 2006;16(5):541-548.

36

QuetiapineQuetiapine

Four openFour open--label studies:label studies:

1.1. Age range 6Age range 6--15 y, Dosage range 10015 y, Dosage range 100--350350

mg/d, Response 2/6 (Martin et al. 1999)mg/d, Response 2/6 (Martin et al. 1999)

2.2. Age range 10Age range 10--17 y, Dosage range 10017 y, Dosage range 100--

450 mg/d, Response 2/9 (Findling et al.450 mg/d, Response 2/9 (Findling et al.

2004)2004)


mg/d, Response 8/20 (Corson et al. 2004)mg/d, Response 8/20 (Corson et al. 2004)


mg/d, Response 6/10 (Hardan & Handenmg/d, Response 6/10 (Hardan & Handen

2005)2005)


7/8

7

37

ZiprasidoneZiprasidone Retrospective case series, 14.15Retrospective case series, 14.15 8.298.29

wkwk

12 subjects12 subjects

Mean age = 11.62Mean age = 11.62 4.38 y; range = 8 to4.38 y; range = 8 to20 y20 y

Mean dose = 59.23Mean dose = 59.23 34.76 mg/d;34.76 mg/d;range = 20range = 20--120 mg/d120 mg/d

Response: 6/12 (50%) on CGIResponse: 6/12 (50%) on CGI--II

No significant weight gainNo significant weight gain

McDougle CJ et al. J Am Acad Child Adolesc Psychiatry. 2002;41:921-927.38

ZiprasidoneZiprasidone 66--week prospective, openweek prospective, open--label studylabel study

12 subjects12 subjects

Mean age = 14.5Mean age = 14.5 1.8 y; range = 12 to 18 y1.8 y; range = 12 to 18 y

Mean dose = 98.3Mean dose = 98.3 40.4 mg/d; range = 20 to 16040.4 mg/d; range = 20 to 160

mg/dmg/d

Response: 9/12 (75%) on Clinician CGIResponse: 9/12 (75%) on Clinician CGI--II

No significant weight gainNo significant weight gain

QTQTcc increased a mean of 14.7 msec; none > 448increased a mean of 14.7 msec; none > 448msecmsec

Malone et al. J Child Adolesc Psychopharmacol. 2007;17:779-790.

39

Aripiprazole in AspergersAripiprazole in AspergersDisorder and PDD NOSDisorder and PDD NOS

1414--week prospective, openweek prospective, open--label studylabel study

25 subjects (6 female, 19 male; age =25 subjects (6 female, 19 male; age =8.6 y, range = 58.6 y, range = 5--17 y)17 y)

IQ = 82, range = 50IQ = 82, range = 50--132132

Target Symptoms = Irritability,Target Symptoms = Irritability,aggression, selfaggression, self--injury (ABC Irritabilityinjury (ABC Irritabilitysubscale scoresubscale score 18)18)

Dose 7.8 mg/d, range 2.5Dose 7.8 mg/d, range 2.5 15 mg/d15 mg/dStigler et al. J Child Adolesc Psychopharmacol. 2009; 19(3):265-274.

40

Aripiprazole in AspergersAripiprazole in AspergersDisorder and PDD NOSDisorder and PDD NOS

Response:Response: CGICGI--I = Much Improved or Very MuchI = Much Improved or Very MuchImproved and aImproved and a 25% improvement in ABC 25% improvement in ABCIrritability subscale score 21/25 (84%)Irritability subscale score 21/25 (84%)

ABC Irritability Subscale Score:ABC Irritability Subscale Score:

Baseline = 28, Endpoint = 8.8Baseline = 28, Endpoint = 8.8

Adverse Effects:Adverse Effects:

Mild tiredness = 16, Moderate tiredness = 1Mild tiredness = 16, Moderate tiredness = 1

Mild EPS = 6Mild EPS = 6

Weight gain = 19, Mean = 2.3 lbs, range =Weight gain = 19, Mean = 2.3 lbs, range = --3.33.3 7.7 lbs7.7 lbs

Stigler et al. J Child Adolesc Psychopharmacol. 2009; 19(3):265-274.

41

Aripiprazole in AutismAripiprazole in Autism

Flexible Dose StudyFlexible Dose Study 98 children and adolescents with autism (age 698 children and adolescents with autism (age 6--17 years)17 years)

with significant irritabilitywith significant irritability

88--week, doubleweek, double--blind, placeboblind, placebo--controlled, parallel groups,controlled, parallel groups,flexiblyflexibly--dosed (2dosed (2--15 mg/day) trial15 mg/day) trial

Aripiprazole (8.5 mg/day) more efficacious than placebo onAripiprazole (8.5 mg/day) more efficacious than placebo onAberrant Behavior Checklist Irritability subscale (P


8/8

8

43






44

Medications Studied forMedications Studied forSocial Impairment in AutismSocial Impairment in Autism

Not effectiveNot effective

FenfluramineFenfluramine

NaltrexoneNaltrexone

LamotrigineLamotrigine

AmantadineAmantadine

RisperidoneRisperidone

FluoxetineFluoxetine

CitalopramCitalopram

45

DD--Cycloserine in Children withCycloserine in Children withAutismAutism

80 chilren (6.580 chilren (6.5 2.8 years; range 32.8 years; range 3--12 years) with12 years) withautistic disorder and significant social withdrawalautistic disorder and significant social withdrawal

88--week, doubleweek, double--blind, placeboblind, placebo--controlled, parallelcontrolled, parallelgroups designgroups design

DD--cycloserine 1.7 mg/kg/day divided twice daily orcycloserine 1.7 mg/kg/day divided twice daily orplaceboplacebo

No drugNo drug--placebo difference on the CGIplacebo difference on the CGI--I, ABC SocialI, ABC SocialWithdrawal subscale, or Social Responsiveness ScaleWithdrawal subscale, or Social Responsiveness Scale

DD--cycloserine generally wellcycloserine generally well--toleratedtolerated

Posey DJ et al.AACAP Poster 3.53, 2008.46

Future DirectionsFuture Directions

Motor Hyperactivity/InattentionMotor Hyperactivity/Inattention

-- DoubleDouble--blind, placeboblind, placebo--controlled trial of atomoxetinecontrolled trial of atomoxetine

-- DoubleDouble--blind, placeboblind, placebo--controlled trial of guanfacinecontrolled trial of guanfacine

Repetitive BehaviorRepetitive Behavior

-- Pilot studies of riluzolePilot studies of riluzole

Aggression, SelfAggression, Self--Injury, Property DestructionInjury, Property Destruction

-- Pilot studies of paliperidonePilot studies of paliperidone

Impaired social RelatednessImpaired social Relatedness- Controlled trial of D-cycloserine + Social Skills Training

- Double-blind, placebo-controlled trial of memantine

- Pilot studies of intranasal oxytocin

47 48

Christian Sarkine AutismChristian Sarkine Autism

Treatment CenterTreatment Center Christopher J. McDougle, MDChristopher J. McDougle, MD David J. Posey, MDDavid J. Posey, MD Naomi B. Swiezy, PhDNaomi B. Swiezy, PhD Kimberly A. Stigler, MDKimberly A. Stigler, MD Craig Erickson, MDCraig Erickson, MD Noha Minshawi, PhDNoha Minshawi, PhD Stacie Pozdol, MSStacie Pozdol, MS Doug Gaebler, MSWDoug Gaebler, MSW Arlene Kohn, BAArlene Kohn, BA Elizabeth Kiefer, MAElizabeth Kiefer, MA Lauren MathieuLauren Mathieu--Frasier, MSFrasier, MS Jennifer Mullett, RN, BC CCRPJennifer Mullett, RN, BC CCRP Jon Diener, BSJon Diener, BS Iryna Ashby, BSIryna Ashby, BS Melodie Rose, BAMelodie Rose, BA

www.iupui.edu/~psycdept/autism/index.htm

(317) 274-8162

Documents

ASD Treatment - 10.10 Mc Dougle 2010